Optometric Office October/November 2019

OPTOMETRIC OFFICE PRODUCTS AND TECHNOLOGY FOR YOUR PRACTICE

OCTOBER/NOVEMBER 2019

CONTACT LENSES:

INSTRUMENTS:

PATIENT CARE:

DOCS SPEAK OUT ABOUT FITTING PRESBYOPES p 7

3 DEVICES FOR DIAGNOSING DRY EYE p 8

A STRATEGY FOR GLAUCOMA DRUG SHORTAGES p 12

FEATURED AT VEW | AN OCT FROM ZEISS,

A NON-MYD FUNDUS CAMERA FROM ESSILOR, AN OCULAR SURFACE ANALYZER FROM COBURN AND MORE p 14 SUPPLEMENT TO VCPN OCTOBER/NOVEMBER 2019

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toric 1. 2019 CooperVision study, data on file. Based on the number of published parameter options available across all soft lenses from Alcon, Johnson & Johnson, and Bausch & Lomb; UK and US; April 2019. ©2019 CooperVision 8524 9/19

OPTOMETRIC OFFICE EDITORIAL STAFF VP, Editorial John Sailer | JSailer@ FVMG.com Editor Joanne Marchitelli | JMarchitelli@FVMG.com

Table of Contents

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Creative Director Production and Web Manager Megan LaSalla | MLaSalla@FVMG.com Contributing Writers Jeff Anshel, OD, FAAO Eric Schmidt, OD, FAAO

DEPARTMENTS BUSINESS STAFF President/Publisher Terry Tanker | TTanker@FVMG.com Regional Sales Manager Eric Hagerman | EHagerman@FVMG.com

EDITORIAL ADVISORY BOARD Jeffrey Anshel, OD • Sherry Bass, OD • Murray Fingeret, OD • Ed De Gennaro, MEd, ABOM • Deepak Gupta, OD • Alan Homestead, OD • Nikki Iravani, OD • Bill Jones, OD Alan G. Kabat, OD • Kenneth A. Lebow, OD, FAAO • Jerome A. Legerton, OD, MBA Scot Morris, OD • John Schachet, OD • Eric Schmidt, OD • Leo Semes, OD Peter Shaw-McMinn, OD • Joseph Sowka, OD, FAAO Jennifer Stewart, OD • J. James Thimons, OD

INDUSTRY ADVISORY BOARD Dwight Akerman, OD, Alcon Laboratories, Inc., a Novartis Company Steve Baker, EyeFinity • Joseph Boorady,OD, TearScience, Inc. Sally M. Dillehay, OD, Visioneering Technologies, Inc. Dave Hansen, OD, Ophthalmic Consultant • Carla Mack, OD, Alcon Laboratories, Inc. Dave Sattler, Dave Sattler Consulting Michele Andrews, OD, CooperVision, Inc. • Ellen Troyer, Biosyntrx, Inc. Millicent Knight, OD, Johnson & Johnson Vision Care, Inc.

Throughout this magazine, trademark names are used. Instead of placing a trademark or registration symbol at every occurrence, we are using the names editorially only with no intention of infringement of the trademark.

2 | Views 3 | One-to-One: Rick Weisbarth, OD, FAAO, Alcon and Think About Your Eyes 4 | Product Buzz 14 | New Product Gallery 16 | At-A-Glance: Daily Disposable Contact Lenses

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FEATURES 7 | CONTACT LENSES: Docs Speak Out About Contact Lenses for Presbyopia 8 | INSTRUMENTS: Allergy Or Dry Eye? There’s A Test For That!

12 | PATIENT CARE: Compliance Amid Dorzolamide Shortages

Images on cover: CIRRUS 6000 from Carl ZEISS Meditec, the RETINA800 from Essilor Instruments, and the IDRA Ocular Surface Analyzer from Coburn Technologies.

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VIEWS Joanne Marchitelli World Sight Day is observed annually on the second Thursday of October. The global event serves to bring awareness to vision impairment and blindness.

The World Health Organization (WHO) released its first World report on vision in advance of World Sight Day 2019, October 10. The report, geared to ministries of health, development agencies, civil society organizations and researchers, practitioners and policy makers from the field of eyecare, hopes to help reduce the burden of eye conditions and vision loss around the world.

According to WHO, there are at least 2.2 billion people around the world with a vision impairment, of whom at least 1 billion have a vision impairment that could have been prevented or is yet to be addressed. Those conditions include short and far sightedness, glaucoma and cataract.

“Eye conditions and vision impairment are widespread, and far too often they still go untreated,” said Dr. Tedros Adhanom Ghebreyesus, WHO Director-General. “People who need eyecare must be able to receive quality interventions without suffering financial hardship. Including eyecare in national health plans, and essential packages of care are an important part of every country’s journey towards universal health coverage.”

“It is unacceptable that 65 million people are blind or have impaired sight when their vision could have been corrected overnight with a cataract operation, or that over 800 million struggle in everyday activities because they lack access to a pair of glasses,” he added.

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WHO RELEASES FIRST WORLD REPORT ON VISION Refractive error, glaucoma and cataract aren’t the only conditions that the report focuses on. Eye conditions, such as dry eye and conjunctivitis are among the main reasons for which patients seek eyecare in all countries, making it important to address. Myopia and diabetic retinopathy, two conditions that are increasing as our population ages, also require vision care. The report states that stronger integration of eyecare is needed within national health services, including at the primary healthcare level, to ensure that the vision needs of more people are addressed, including prevention, early detection, treatment and rehabilitation.

Removing obstacles to eyecare is necessary, too. The report states such challenges as inequalities in the coverage and quality of prevention, treatment and rehabilitation services; a shortage of trained eyecare service providers; and poor integration of eyecare services into health systems, as some of the obstacles people face in receiving proper eyecare.

The report recommends five actions: 1. Make eyecare an integral part of universal health coverage.

2. Implement integrated people-centered eyecare in health systems.

3. Promote high-quality implementation and health systems research complementing existing evidence for effective eyecare interventions.

4. Monitor trends and evaluate progress toward implementing integrated people-centered eyecare.

5. Raise awareness and engage and empower people and communities about eyecare needs. *** Joanne Marchitelli | Editor | JMarchitelli@FVMG.com

identify it and adapt to it quickly. Just about the time that things become comfortable—it is probably time to be ready to change again. Subsequently, TAYE’s campaign for 2020 and beyond will use different tactics and channels than when the initiative first started.

JM: TAYE’s campaign has seen tremendous success in the last few years. Can you recap those successes for us?

ONE-TO-ONE

Rick Weisbarth OD, FAAO

Rick Weisbarth, OD, FAAO, vice president of professional affairs for U.S. Vision Care, Alcon, was named chairman of the Think About Your Eyes (TAYE) advisory board for 2019. He has been with Alcon for over 37 years and has represented the company on the advisory board at TAYE. Here, we ask him about his role in the TAYE campaign.

Joanne Marchitelli: What experiences from your three decades in the industry have helped guide you in the position of chairman of Think About Your Eyes?

Rick Weisbarth: Experience has shown me that most opportunities in the business world, as well as in life, require developing a strategy, sticking with it and then executing the plan with excellence. TAYE has a single strategy aimed to create national public awareness about the importance of seeing an optometrist for a comprehensive annual eye exam.

Educating people is no easy task—it requires a village.

By working together, optometrists and their staffs, the leadership states, the American Optometric Assocation (AOA) and industry can create a better tomorrow in vision care. All of us bring different talents, experience and expertise to any project we tackle, and this diversity creates a resultant product that is always better. TAYE has been no different. We are in a much better position to execute our plan and achieve success due to our joint efforts.

Finally, you must be agile and willing to change. So much has changed in the eyecare world over the last threeplus decades. It is always important to anticipate change,

RW: TAYE has seen success both within the industry and with patients reacting to the message. On the industry side, we’ve successfully grown the partner base to represent a wide variety of industry companies, without whom the campaign would not be possible. Additionally, we have the support of the AOA, 45 state optometric associations and Armed Forces Optometric Society, which has led to more than 22,000 ECPs on the online locator.

Through the use of a multichannel strategy to drive results, TAYE generated 3.95 million eye exams in 2018, and the website was visited more than two million times that year alone. Thanks to industry support, TAYE is able to continuously meet consumers where they get their information with a positive message around the need to see an optometrist for an eye exam and overall vision health.

JM: What are your top priorities for 2020?

RW: We have adjusted our tactics to reflect the new ways in which consumers are receiving their eyecare and healthcare information. We are continuing with national television, but we are adding Hulu and YouTube to our mix to capture the “cord cutters” who are leaving traditional television to watch content on-demand. We are also investing in Facebook and Instagram advertising—again because we can target our audience efficiently and effectively. We are continuing with web display ads but utilizing Google Artificial Intelligence to target and re-target people based on their web search history. This approach is working, and we have seen a 30% increase in people searching for doctors of optometry between January and June 15, 2019, versus the same time last year.

JM: What can optometrists in private practice do to help support the initiative?

RW: First, become involved. Ensure that your staff, partners and colleagues know what TAYE is about and utilize the available resources to educate patients. Second, support the companies that are supporting you—TAYE is made possible by 18 industry partners—partners that are dedicated to growing the industry and bringing patients into your office.

Third, ask every vendor/company that you work with to support the TAYE effort. The more industry members that support the campaign, the bigger our effort can become.

And finally, ensure your practice is being seen by patients.

Confirm your practice’s information is correct on the locator. Download promotional materials that show your involvement with TAYE. This is the campaign that ODs have been requesting for decades. By increasing the awareness about the importance of comprehensive annual eye exams, we can improve the vision, eye health and general wellness of millions of Americans. As a result, patients win, ECPs win and the eyecare industry wins. *** O p tometr ic O ffic e. c om | O c tob er /November 2019

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PRODUCT | BUZZ LAUNCHES, PROMOTIONS, MERCHANDISING, EVENTS AND OTHER THINGS TO KEEP YOU IN THE KNOW. proven to be invaluable to everyone involved, and with new honorees every year, it just keeps getting better.”

SUBMISSIONS FOR COOPERVISION’S 2020 BEST PRACTICES OPEN CooperVision, Inc. announced its fifth annual search for the nation’s 2020 Best Practices at Vision Expo West in Las Vegas. The company kicked off the milestone year with a celebration for its program, which recognizes optometric practices that advance the profession through innovation, industry leadership, and the provision of exceptional patient experience.

Since its inception, 40 eyecare practices across the U.S. have been named as honorees. “In the beginning, we had a vision for Best Practices and what it might become, but the extent to which the program has grown and evolved is something we could have never anticipated,” said Michele Andrews, OD, senior director of professional and academic affairs, North America, CooperVision. “Bringing together the honorees to exchange ideas, tackle challenges, and build camaraderie has

Dr. Karl Lamprecht has been named president and CEO, Carl Zeiss, effective April 1, 2020. He will succeed Prof. Dr. Michael Kaschke.

Medical Optometry America (MOA) signed an agreement with Associates in Eyecare–Optometrists (AIE) under which AIE will become the nation’s first group of

All U.S. optometry practices currently fitting contact lenses are eligible to apply. Best Practices candidates are encouraged to submit practice profiles and stories, sharing their insights and experiences in innovation, industry leadership and patient experience.

Go to EyeCareBestPractices.com

2020 PERSONS OF VISION AWARD RECIPIENT ANNOUNCED Prevent Blindness has announced that the recipient of the 2020 Persons of Vision Award will go to VSP Global and its president and CEO Michael Guyette. The event will take place on March 26, 2020, in New York City in conjunction with Vision Expo East.

All proceeds from the event will go to support the sight-saving programs of Prevent Blindness.

The Prevent Blindness Persons of Vision Award recognizes an individual, corporation and/or organization whose inspired outlook champions healthy vision and its importance for a healthy life. VSP Global was selected as the recipient of the Persons of Vision Award for its 65-year commitment to a mission of helping people see, as well as its long-term support and partner-

Michael Guyette has long been an advocate for making health insurance better aligned with the needs of consumers. He leads VSP Global’s vision to provide access to affordable, high quality eyecare and eyewear to its nearly 90 million members.

ship with Prevent Blindness.

“As we enter the year 2020, it seems only fitting that we honor the work of all the employees at VSP Global, including Michael Guyette, for their work which has had such a tremendous, positive impact on improving vision and keeping eyes healthy every day,” said Jeff Todd, president and CEO of Prevent Blindness. “Prevent Blindness and our affiliates have been fortunate to be long-time partners in their generous works. We invite everyone to help us celebrate this milestone year and the great efforts of Mr. Guyette and all of those at VSP Global who help promote and protect healthy vision.”

“This recognition is a testament to the incredible impact our organization has made since it was founded in 1955,” said Guyette. “I’m honored to share it alongside VSP network doctors and our employees who have contributed so much to change the lives of so many by expanding access to eyecare for as many people as possible.”

Go to PreventBlindness.com/ PersonOfVision

independent optometric practices to adopt the MOA Brand.

University has been awarded a $60,000

New England College of Optometry has announced that Morris Berman, OD, MS, has joined the faculty as an adjunct professor.

her project, “Modeling Corneal Endothelial

Loretta B. Szczotka-Flynn, OD, PhD, FAAO, professor of ophthalmology and visual sciences at Case Western Reserve

Academy of Optometry Foundation

4 Oct o be r / N o v e m b e r 2 0 1 9 | O p to m e tri c O f f i c e .c om

Allergan Foundation Research Grant for Cell Health Parameters as Predictors of Keratoplasty Stress.” The American partners with the Allergan Foundation to award the grant.

NORA ANNOUNCES AWARD WINNERS The Neuro-Optometric Rehabilitation Association, International (NORA) recognized the following individuals and association at NORA’s 28th Annual Conference in Scottsdale, AZ, for their important contributions to NORA and the field of neuro-optometric rehabilitation.

Eric Singman, MD, PhD, and Patrick Quaid, OD, FCOVD, PhD, were co-recipients of the Advancement of Neuro-Optometric Rehabilitation Award in recognition of their contributions to advancing the field of neuro-optometric rehabilitation. “Eric and Patrick have continually demonstrated their commitment to advancing and sharing the science and practice of neuro-optometric rehabilitation,” said Susan Daniel, OD, president, NORA. The Concussion Legacy Foundation (CLF) was presented with the Advancement of Sciences Award for its unique and valued contribution to the science of neuro-optometric rehabilitation. Founded in 2007, the CLF supports athletes, veterans, and all affected by concussions and chronic traumatic encephalopathy achieve smarter sports and safer athletes through education and innovation through programs designed to educate and protect athletes at both the local and national level.

has continued to honor their legacy through his lectures nationally and internationally, his published papers, and his dedication to patients in his community.”

Gary Esterow, NORA executive director, was presented with the President’s Award for demonstrating superior service to the organization and to the field of neuro-optometric rehabilitation.

Go to NORA.org

WICHITA STATE FRESHMAN AWARDED SCHOLARSHIP Envision, Inc. awarded the High Touch Computer Information Systems Scholarship for the Blind or Visually Impaired at Wichita State University (WSU) to Andrew McLeod, a freshman at WSU majoring in computer science. The scholarship, funded by Wichita-based software, technology and communications company High Touch Technologies, provides $10,000 in tuition support to a WSU student with vision loss who plans to major in computer information systems, computer science, information technology or a related technology field.

Go to EnvisionUS.com continued on page 6

Smart Vision Labs was a top ten finalist for Best Telemedicine Company category in the UCSF Digital Health Awards.

ABB Optical Group announced plans to expand into the Canadian market in 2020.

ProQR Therapeutics received Fast Track designation from the Food and Drug Administration for QR-1123, a treatment for autosomal dominant retinitis pigmentosa.

Oculis announced the appointments of two leading ophthalmology specialists to its scientific advisory board: Eric Donnenfeld, MD, an internationally recognized expert and pioneer in refractive, cornea and cataract surgery; and Pr. Ramin Tadayoni, MD, PhD, renowned professor and ophthalmologist specializing in retinal diseases, retinovitreal surgery and ophthalmic imaging.

RevCycle Partners, has launched WeVerify, a comprehensive service that verifies patient benefits and drives new revenue opportunities for the practice.

Fast Company has announced that it will honor revered nonprofit Braille Institute of America and New York-based creative agency Applied Design Works in its 2019 Innovation by Design Awards. The companies partnered to create Atkinson

DeAnn Fitzgerald, OD, vice president of NORA, was honored with NORA’s Founding Father’s Award in recognition of her lifelong dedication to the exploration, elucidation, and enhancement of the concepts surrounding the nature of the human visual process.

Curt Baxstrom, OD, FCOVD, FAAO, was presented with the William and Diana Ludlam Educators Award in recognition of his commitment to serving students and patients in the neuro-optometric rehabilitation area. “Bill and Diana Ludlam were instrumental in helping to establish neuro-optometric rehabilitation in the academic setting,” said Daniel. “Curt

Andrew McLeod (center), a first-year student majoring in computer science, receives a $10,000 check from Heather Hogan, senior vice president, Foundation & Mission Services at Envision, and Kevin Colborn, senior vice president of technology solutions at High Touch Technologies.

O p tometr ic O ffic e. c om | O c tob er /November 2019

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PRODUCT | BUZZ

CONTINUED

LAUNCHES, PROMOTIONS, MERCHANDISING, EVENTS AND OTHER THINGS TO KEEP YOU IN THE KNOW. NATIONAL VISION TO AWARD $7,000 IN GRANTS TO STUDENTS

REGISTRATION OPEN FOR ISVA ANNUAL CONFERENCE Registration is now open for Beyond 20/20, the 4th Annual International Sports Vision Association (ISVA) conference, February 6 to 8, 2020, at the Bahia Resort Hotel in San Diego, CA. This year’s meeting kicks off with two separate day-long pre-conference workshops, each offering up to six hours of continuing education (COPE approval pending) credits.

“One workshop is geared towards those interested in establishing a sports vision practice to demonstrate techniques and practices that add unique value to athlete clients,” explained conference education cochair Greg Appelbaum, PhD. “The other workshop is designed for sports vision professionals who are already conducting specific vision skill testing and actively engaged in working with athletes and/or teams and looking to provide added services and value to their clients.” Each workshop will be limited to 40 participants.

The ISVA General Conference on February 7 to 8 will provide an additional 13 hours of continuing education (COPE approval pending).

Register by Dec. 5, 2019, to receive an early bird conference discount for the General Conference. Current and new ISVA members receive reduced pricing. Any student in a professional degree program or resident in a postgraduate program is eligible for a complementary membership.

Go to SportsVision.pro

National Vision Holdings, Inc., is accepting entries for its annual grant program for third- and fourth-year optometry students. In honor of 2020’s playful connection to visual acuity, this year’s essay topic calls on students to share their “Vision” and detail their predictions for how the optometry profession will evolve in the upcoming decade. National Vision is also challenging students to explain how they’ll shape the future of the profession in a positive way. For the fifth consecutive year, the company will offer entrants the chance to win a $5,000 grant and two runner-up grants totaling $1,000 each.

Students in good standing with a school in the U.S, Puerto Rico or Canada have the option of answering the essay prompt in the form of a 500word written essay or a short video (no longer than five minutes). In either format, applicants are encouraged to address questions about what future they foresee for the industry and why, such as: • Have you observed any changes in the profession recently that you feel will grow in the years to come?

• Are you following any research that could change the way optometrists practice in the future?

• Do you think patient expectations or needs will evolve in the decade of the 2020s?

Submission deadline is Jan. 31, 2020.

The winners, including two runnerup recipients, will be announced by March 1, 2020.

Go to NationalVision.com

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Hyperlegible, a typeface designed to increase legibility for those readers with low vision. The development has received recognition in the Graphic Design category.

Advancing Eyecare has acquired Ophthalmic Instruments, Inc. Carla Mack was named global head of professional affairs for vision care for Alcon.

Cognivue received FDA approval for Cognivue Advanced, a computerized test of cognitive function.

SUNY College of Optometry’s University Eye Center has named Deborah Amster, OD, chief of pediatric service. She will head the implementation of the new Center for Pediatric Eye Care set to open in early 2020.

The New England College of Optometry has announced that Kristen Brown, OD, has been selected to be the associate dean of clinical affairs.

The American Academy of Optometry has announced that Jocelyn Ou, OD, has been selected as this year’s recipient of the Bert C. and Lydia M. Corwin Contact Lens Residency award.

Coherent Eye Care has named Justin Manning, OD, MPH, as director of population health strategies and provider education.

Luneau Technology has added Melissa Renfrow to its Clinical Application Specialist team.

VSP Vision Care has acquired North Carolina-based Community Eye Care.

The National Center for Children’s Vision and Eye Health at Prevent Blindness presented the fifth annual Bonnie Strickland Champion for Children’s Vision Award to Anne L. Coleman, MD, MPH, UCLA Stein Eye Institute.

Blanchard Contact Lenses has hired Monica Shea as Northeast regional account manager.

CONTACT LENSES

DOCS | SPEAK OUT

Fi t t i n g P r e s b y o p e s with C ontac t L ens es About 30% of the adult U.S. population has presbyopia. The condition, which begins to appear in patients after 40 years of age, is a common reason people cite for ditching contact lenses. But, it doesn’t have to be that way. Today’s lens technologies and designs are making it possible for presbyopes to continue to wear contact lenses. The only caveat? They take trial and error to find the best fit. As one OD in our Docs Speak Out survey this month said, “Not one works for everyone, so it’s great to have plenty of options.” From monovision to multifocals, options are plentiful to help keep your patients in their lenses.

What percentage of your patients have presbyopia? fewer than 10%

0

10% to 25%

10%

Figure 2. Keratoconus risk score table. In this individ50% ual, after the first25% two to metrics are placed in the table, they 75% are already at a50% hightorisk of having keratoconus.

more than 75%

58% 30% 2%

Can you share a success story of how you kept a patient in contact lenses and kept them happy?

“Patient was pseudophakic in one eye with presbyopia correcting implant and a single vision contact lens in other eye. Fit her with multifocal contact lens and she was very happy!”

“Our office is 95% daily disposable contact lens sales. Of our contact lens sales, 30% are multifocal contacts. A successful multifocal lens fit is a happy patient for life—and they are the best referral source out there!

“Listen first to a patient’s lifestyle requirements and then build realistic contact lens expectations for the individual patient.”

“A new patient came in and told me that her doctor told her she can no longer wear contact lenses due to her presbyopia. I put her in Bausch + Lomb progressive lenses and she is ever so happy.”

For contact lens fittings, do you trial both monovision and multifocal lenses?

NO 40

What do you recommend to your patients with presbyopia for vision correction? (check all that apply)

88% 84% 66%

60% 60%

%

60%

YES

ith k ses for l s w wor ar) len ses oca we nce ear ve ses ses las ultif time ssi len ista for n len g e d t t r e m c c r t v a ta fa rs rog ssi and r par ont hp for eade con gre ar fo al c wit ion ses r r pro we es ifoc vis ses len ounte h ( yday lens t o l t s t n o u a c r t b ve tac gl m ta e-c mo e on eye coner-th c ov

“Monovision with over glasses to help far vision while driving.”

“I converted a patient from monovision to multifocal lenses. She literally broke out in tears of joy!”

“Alcon’s DAILIES Total1 solve both the near vision and dry eye symptoms for my patients.”

“A gentleman, an attorney, has worn contacts (RGP) since his teen years. When the time came that he needed more than just putting on ‘readers’ when he needed them was switched to Metro’s bifocal. He was very happy and has now retired.”

“Monovision gradually has been most successful for me if patients have worn contact lenses habitually. New presbyopes are not as likely to want contacts.”

“Just be sure to set proper expectations beforehand.”

“An amblyopic patient was losing near in best eye. Was in single vision only and

put in to a multifocal contact lens in one eye and asked what kind of magic I was using. Great outcome!”

“Many patients require several attempts.”

“Can’t think of specific patients, but there have been many smooth transitions with emerging presbyopes changing them into Johnson & Johnson Vision’s 1-Day ACUVUE MOIST for Presbyopia or CooperVision’s Biofinity multifocal.”

“I fit myself as a testament.”

“I had an older patient who was hyperopic that I introduced to a multifocal. She was thrilled to be able to wear her Biofinity multifocal and still see far away and close.”

“Patients that have trouble reading with their contacts are really happy when we can help them read.”

“I had a patient who was struggling in her contact lenses at work, changed her to Biofinity multifocals and she said I changed her life!”

O p tometr ic O ffic e. c om | O c tob er /Novembe r 2019

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INSTRUMENTS

ALLERGY OR DRY EYE? THERE’S A TEST FOR THAT! A look at two ways to diagnose dry eye disease and the latest method that can determine if the patient is suffering from allergies instead.

B y J ef f A nshl e r, OD , FAAO There are many causes of dry eye disease (DED), making it a challenge to efficiently test for the cause of the disorder. Most practitioners rely on one of the many questionnaires that are available but those take some time to complete and depend on patient recall of their symptoms. Dry eyes and ocular allergies can have many overlapping complaints, making it more challenging to determine the specific disorder needing therapy.

It would be expedient if we could distinguish between the two forms of dry eye—aqueous deficient (ADDE) and evaporative (EDA)—quickly

“…just enhancing the lipid layer of the tears requires addressing the ‘root’ of the tear layer, which means enhancing the mucin layer as well.”

and accurately, as well as confirm the diagnosis of dry eye vs. allergic conjunctivitis.

Tests that are available to determine the source of DED include tear film breakup time, which determines tear film integrity, Shirmer’s Test and Zone Quick (phenol red thread) for tear volume, tear osmolarity, rose bengal and lissamine green for cell

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integrity, lid wiper epitheliopathy to observe increase in friction between the lid margin conjunctiva and the ocular surface, and a measurement of lactoferrin protein levels in the tear film.

Testing the tear layer involves more than just any one of these tests.

Because of the variety of causes and several factors involved in tear film instability, practitioners should

“One way is to promote yourself as a ‘dry eye center’ to your patients, which can certainly achieve recognition in your community.”

incorporate these tests into a preexamination routine. Any patient who complains of excessive or deficient tearing, redness, irritation, discharge, or any other typical anterior ocular complaint should be screened prior to seeing the doctor.

TESTING TEARS One of the more established tests is the tear osmolarity test. The TearLab Osmolarity System (TearLab) is intended to measure the osmolarity of human tears to aid in the diagnosis of dry eye disease in patients suspected of having DED. This test, in conjunction with the TearLab Osmolarity System, provides a quick and simple method for determining tear osmolarity using nanoliter (nL) volumes of tear fluid collected directly from the eyelid margin. The Test Card is held by the Osmolarity Test Pen for safe collection. The TearLab Osmolarity Test utilizes a temperature-corrected impedance measurement to provide an indirect assessment of osmolarity.

After applying a lot-specific calibration curve, osmolarity is calculated and displayed as a quantitative numerical value.

Another point-of-care instrument is InflammaDry (Quidel). The device is a rapid, in-office test that detects elevated levels of MMP-9, an inflammatory marker that is consistently elevated in the tears of patients with DED. Using direct sampling microfiltration technology, InflammaDry accurately identifies elevated levels of MMP-9 protein in tear fluid samples taken from the inside lining of the lower eyelid, the palpebral conjunctiva.

While much of the media surrounding DED is directed toward lipid layer enhancement, just adding “oils” to a tear layer is not adequate in resolving the underlying source of the disease process. Consider a visit

to the dentist with a cavity in one tooth. They would not think of just “capping” the tooth without treating the underlying root to address the source of the degeneration. Likewise, just enhancing the lipid layer of the tears requires addressing the “root” of the tear layer, which means enhancing the mucin layer as well.

Lactoferrin is an antiviral, antibacterial, iron-binding protein that is particularly vital to tear production. It is also a mucous-specific, anti-inflammatory molecule. Serum lactoferrin is released from the lacrimal gland in a manner similar to serum IgG and possibly from tear neutrophils during infection and inflammation. By binding iron, lactoferrin prevents the pathogen from obtaining sufficient iron, which it relies upon for growth.

TESTING LACTOFERRIN LEVELS The most recent development in tear evaluation is the TearScan 300 Tear Analyzer (Advanced Tear Diagnostics). Its quantitative tests can distinguish the source of dry eye (ADDE or EDA) vs. allergic reaction (IgE). A technician draws a sample of tears into a micropipette and then transfers this to a test strip incorporated into a cassette. This cassette is then inserted into a computerized unit that evaluates the concentration of lactoferrin and IgE, thus offering a numerical evaluation of those molecules. The time of the test is typically 10 minutes. Thus, a determination of the condition can be accomplished while the patient is still in the office and treatment can be directed immediately. Lactoferrin testing is reported to be the most reliable, single marker in the diagnosis of DED. The TearScan 300 has been cleared by the FDA and provides the practitioner more precise clinical data regarding lactoferrin levels in the tear film. Multiple studies have dem-

onstrated the low value of normal tear lactoferrin levels to be about 0.9 mg/ mL. Values less than this indicate lacrimal gland dysfunction, with the smaller the number, the greater the dysfunction of the lacrimal gland.

Medicare and most insurance companies reimburse the TearScan 300, using codes 83520 (lactoferrin) and 82785 (IgE). Eyecare providers must first register as a “lab” and obtain a Clinical Laboratory Improvement Amendments (CLIA) number to get the reimbursements. In most states, optometrists qualify as lab directors for Class I and Class II Certification.

This type of certificate is issued to a laboratory that performs waived or non-waived (moderate complexity) testing. Advanced Tear Diagnostics will assist the practitioner in gaining their certification.

While diagnosing and treating dry eye can seem daunting and overwhelming, there are many avenues to walk down when deciding what to use in the clinic. One way is to promote yourself as a “dry eye center” to your patients, which can certainly achieve recognition in your community. However, the best way to make gains in this area is being successful with your existing patients, who will undoubtedly tell their friends and loved ones about your abilities.

Getting positive results is your best advertising. O|O

Jeffrey Anshel, OD, FAAO, is founding president of the Ocular Nutrition Society and is in private practice in Encinitas, CA.

WHERE TO FIND IT Advanced Tear Diagnostics 888.328.1941 | AdvancedTearDiagnostics.com TearLab 855.832.7522 | TearLab.com Quidel 800.874.1516 | Quidel.com

O p tometr ic O ffic e. c om | O c tob er /Novembe r 2019

9

Help increase patients’ immediate in-practice purchasing power and make their path to quality eye care and eyewear easy to see.

There are opportunities along a patients’ journey to clear vision to influence their decision-making process and help them move forward with the specialty eye care treatments they need and premium eyewear they want — including frames, lenses, multiple pairs, prescription sunwear and annual supplies of contact lenses. CareCredit can help every step of the way.

Step 1: Explore Studies show 62% of patients research providers, treatments and products online and 67% explore payment options.1 You can attract more patients by adding information about CareCredit to your practice website. Pre-coded assets including pages, banners, buttons and apply links can be downloaded at carecredit.com/adtoolkit.

1 2 3 4

CareCredit Path to Purchase reserach 2018.

Average 2018 1st ticket sales in an independent optometry practice that accepts CareCredit.

Management and Business Academy™ (MBA) for ECPs, ADA Research and Information Center.

Cardholder Engagement Study, 2018, conducted for CareCredit by Chadwick Martin Bailey.

Step 2: Engage Next, patients engage with a practice by calling to set an appointment and browsing the frame selection before their exam. Letting them know about financing options could increase their eye care and eyewear options.

Patients who opened a CareCredit account in an optical practice had an average out-of-pocket purchase of $5712 which is significantly higher than the industry average.

As patients browse your frame selection, let them know promotional financing may be available by displaying CareCredit counter displays and window clings.

Step 3: Shop Don’t let patients leave empty-handed. Product sales account for 58%3 of a practice’s gross revenue, but the average capture rate is only 52%. Increasing patients’ immediate purchasing power may help keep prescriptions in house. Capturing just one additional patient a day at the CareCredit average out-of-pocket purchase of $571 may generate more than $10,000 in additional revenue a month.

You can fully utilize the power of promotional financing by showing patients what their estimated monthly payment might be using the online payment calculator.

Step 4: Advocate When patients leave happy, they may be more likely to return, write positive online reviews and refer friends and family. 92%4 of patients surveyed who used CareCredit to make an eyewear purchase said they are likely to purchase from that practitioner again.

For all the resources CareCredit has available to help you optimize opportunity along the patient journey, call 800.859.9975 (press 1, then 6) or visit carecredit.com/providercenter.

®

PATIENT CARE

COMPLIANCE AMID DORZOLAMIDE SHORTAGES

How to make sure drug availability problems don’t turn into compliance issues.

B y Er i c Schmi dt , OD , FAAO A shortage of dorzolamide due to manufacturing problems once again raises questions of how prepared we are to make sure patients continue getting uninterrupted IOP control.

There are other options, but the real concern is compliance. When patients have formed good habits with their eye drops, we’re justifiably concerned that a disruption could throw them off their game. When they take their prescription to the pharmacy, the last thing we want is for them to be turned away or delayed. They need their medication – reliably, consistently, and without any surprises to disrupt what may be tenuous compliance.

Whether we’re prescribing dorzolomide as a stand-alone drug, as a prostaglandin adjunct, or as a part of a combination drop, I’ve found that dorzolamide has not been reliably available, and the pharmacy’s substi-

tutions are generally undesirable. I’ve made proactive changes to ensure my patients’ IOP remains controlled with reliably available medications.

MAKING SUBSTITUTIONS When the pharmacy calls to say it doesn’t have generic dorzolamide and we need to pick another drug, what do we do? Branded dorzolamide (TruSopt, Merck) is no longer supported, and there are no other easy carbonic anhydrase inhibitor (CAI) substitutions.

The right options for a patient might depend on allergies, tolerability, and the dosing regimen. One option is to abandon CAIs. We can switch to an alpha-2 adrenergic receptor agonist (α2 agonist), brimonidine (Alphagan P, Allergan), which we know has a similar effect on IOP1 and will be covered in most cases. Other options include the rho kinase inhibitor, netarsudil (Rhopressa, Aerie

12 Oct o be r / N o v e m b e r 20 1 9 | O p to m e tri c O f f i c e . c om

Pharmaceuticals), or a generic beta blocker. These are all potential substitutes for dorzolamide as an adjunct to a prostaglandin such as bimatoprost (Lumigan, Allergan).

If we’ve been prescribing the generic CAI/beta blocker combination, dorzolamide/timolol, we could prescribe the branded version (Cosopt, Akorn), but it’s unlikely to be covered.

Instead, I prescribe an α2 agonist/ beta blocker combination, brimonidine /timolol (Combigan, Allergan).

The effects are similar,2 but there is no problem with availability of Combigan, and most healthcare plans cover the product at some level.

To my mind, this is far preferable to an alternative floated by pharmacies that still have some quantity of dorzolamide: prescribing the two components separately. Instead of taking one combination drop twice per day, patients would need to use

“I don’t take it lightly that patients with glaucoma will likely be using their drops for life.”

dorzolamide and timolol separately two times each. We know that whenever we add another drop, compliance decreases significantly,3 which means we could expect to see compliance problems and elevated IOP. Compliance would be further threatened by toxicity and cost. Every time we add another drop on the ocular surface, we increase the risk for adverse effects, such as redness, itching, blurred vision, and keratitis, all of which make patients less likely to instill all their drops. And going from one drop to two would mean paying for two, a problem for patients that ranges from annoying to financially unattainable, potentially affecting compliance.

A SHIFT TO BRANDED MEDS When a problem with generic drug manufacturing processes leaves us in the lurch, I always look at what branded options are available and covered by insurance. Branded pharmaceuticals generally have more consistent manufacturing and uninterrupted availability – a big plus for glaucoma medication compliance.

For example, when this shortage started, I switched to Combigan, and my patients no longer encounter problems at the pharmacy. The pharmacy no longer calls my staff, who in turn don’t need to ask me for a different prescription. I know my patients will get exactly what I prescribed and it’s likely to be covered. Combigan and generic dorzolamide/timolol are comparable in price as well. It’s definitely a misconception that branded drugs cost more than generics.

Although I made this switch in response to the shortage, my first choice is generally a branded product until an insurance company tells me it’s not covered. I want quality, consistency, and well-studied side effect profiles. Generics are only

obligated to replicate the active ingredient, not the buffers, wetting agent, and preservative. Variations in drug concentrations and the pH level can affect penetration.

I like knowing exactly what is in that bottle, active and inactive, and how it affected the ocular surface in clinical trials. Generics that have not been studied on human eyes may have different side effects, so patients can suddenly experience redness or other issues. The extrinsic agents that make up a drop are really important to its desired performance. This is true in many generic medications, but the concerns are greater in a topical eye drop, compared to an oral drug. A branded or generic erythromycin pill will dissolve in the gut and enter the bloodstream without incident, but the variables in a generic eye drop risk everything from efficacy to toxicity.

What’s more, I don’t take it lightly that patients with glaucoma will likely be using their drops for life.

They need the best-fit medication, affordable, readily available, and posing no unnecessary compliance challenges. Every time I see my patients back, we’re always looking ahead at the best choices and, in the interest of compliance, emphasizing stability and predictability.

PATIENTS AS ADVOCATES We have to talk with patients proactively about shortages and manufacturing problems. Ideally, I’d like to explain this to patients and make a switch before they encounter a problem at the pharmacy so there is no interruption. Just in case some drug shortage catches me unaware, I note “Dispense as written/prescribed” on my prescriptions. I tell patients to stick to the plan and not submit to any cheaper or generic offers at the pharmacy, explaining that they will hear it’s “just as good,” but that’s simply

not true. I give patients a sample and tell them that’s how their bottle should look. At follow-up appointments, I ask patients to bring their drops, and then I check that they’re using what I prescribed. Overall, this approach gives me greater control over what patients are using. It also lets me get ahead of availability problems with generic drugs by sticking to branded medications whenever possible. O|O

REFERENCES 1. Katz LJ, Simmons ST, Craven ER. Efficacy and safety of brimonidine and dorzolamide for intraocular pressure lowering in glaucoma and ocular hypertension. Curr Med Res Opin. 2007 Dec;23(12):2971-83.

2. Goi FJ, Brimonidine/Timolol Fixed Combination Study Group. 12-week study comparing the fixed combination of brimonidine and timolol with concomitant use of the individual components in patients with glaucoma and ocular hypertension. Eur J Ophthalmol. 2005 Sep-Oct;15(5):581-90.

3. Robin AL, Covert D. Does adjunctive glaucoma therapy affect adherence to the initial primary therapy? Ophthalmology.

2005 May;112(5):863-8.

Eric Schmidt, OD, FAAO, is founder of Omni Eye Specialists in Wilmington, NC. He lectures internationally on glaucoma, diabetes and retinal disorders.

WHERE TO FIND IT Akorn 800.579.8327 | Akorn.com Aerie Pharmaceuticals, Inc. 919.237.5300 | AeriePharma.com Allergan 800.347.4500 | Allergan.com Merck 800.444.2080 | Merck.com

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NEW PRODUCT | GALLERY ZEISS LAUNCHES CIRRUS 6000 Carl ZEISS Meditec expands its CIRRUS OCT with the launch of its new CIRRUS 6000, 100kHz ultra-fast OCT system for advanced care practices. CIRRUS 6000 is the latest addition to the company’s portfolio of OCT devices that are designed to meet the needs of all types and levels of practices and/or clinicians. It offers clinicians high speed and high throughput to help manage large patient volume faster, all while improving imaging and image quality. The 100kHz speed of the CIRRUS 6000 allows clinicians to scan patients faster, with increased efficiency and improved imaging detail. Additional features include wider and deeper OCT/OCTA scans with 12 x 12 mm OCTA and B-scan depth up to 2.9 mm; HD AngioPlex scan, a new scan type that provides more detail; new workflow protocols to aid in increasing efficiency; and a patient-friendly “Wellness Report” to help educate the patient.

Zeiss.com

ESSILOR INTRODUCES RETINAL IMAGING SYSTEM Essilor Instruments announced the launch of The RETINA800 non-mydriatic fundus camera. Its fully automatic retinal image capture allows for easy screening and detection of retinal pathologies. RETINA800 is fast to operate, has a space-saving design, and provides excellent image quality. Delegation is made easy with the intuitive and easy-to-use, tablet-driven interface.

Essilor.com

LUNEAU TECHNOLOGY UNVEILS NEW DRY EYE MODULE Luneau Technology announced an optional Dry Eye Module that can be added to new VX120+ Anterior Segment Analyzers. Compared to a traditional slit-lamp examination, the Dry Eye Module allows eyecare professionals to more easily engage and retain patients using the onboard, full color monitor to show initial test results along with treatment results over time. The optional Dry Eye test battery can be activated at the press of a button and includes tear break up time, tear meniscus measurement and color imaging of the meibomian glands.

LuneauTechUSA.com

ALCON OFFERS AN OPTION FOR NEW CONTACT LENS WEARERS Alcon’s latest contact lens is targeted for the new contact lens patient. PRECISION1 contact lenses were designed to address the common reasons why new wearers discontinue wear within the first year, such as poor vision, poor comfort and handling issues. A new lens material–verofilcon A with Class 1 ultraviolet-blocking capabilities, created by Alcon Research and Development was used for the lens. Alcon also added its proprietary SMARTSURFACE technology, a permanent, micro-thin, high-performance layer of moisture at the lens surface that helps support a stable tear film to deliver lasting visual performance to the lens. PRECISION1 contact lenses have been available at select eyecare professional offices since early September, and they will become more widely available in 2020.

Alcon.com 14 Oct o b e r / N o v e m b e r 2 0 1 9 | O p to m e tri c O f f i c e . c om

KONAN MEDICAL ANNOUNCES 2ND GENERATION PUPILLOGRAPH EyeKinetix, Konan Medical’s 2nd generation automated, objective pupillograph is smaller, faster, easier to use and less expensive than its predecessor, RAPDx. EyeKinetix features the RAPDx objective, automated test to assess relative afferent pupillary defects in less than one minute. These measures have historically been performed manually with a swinging flashlight method generally regarded as being difficult for clinicians to do well. The EyeKinetix also measures high- and low-light pupil sizes which may be useful to physicians in planning for multifocal IOLs, contact lenses and refractive surgery implications.

KonanMedical.com

RIGHTEYE RELEASES AT-HOME OCULOMOTOR TRAINER RightEye has released its fully commercialized version of EyeQ Trainer, its oculomotor exercise program. This version adds flexibility to both workflows and the user experience so doctors have more control and patients have more choices. Under the supervision of a health care provider, customized computer-based exercises are automatically assigned to patients when deficiencies are identified by RightEye’s eye-tracking EyeQ Tests.

The exercises take about ten minutes per sitting, and can be completed using any computer or tablet, for up to 30 days.

After the patient has completed their prescribed training program, they return to their provider for retesting. According to the company’s data, patients using EyeQ Trainer experienced an improvement of up to 17% in their functional vision measurements after just one week of use, and 93% of patients reported feeling better.

RightEye.com

VSP OPTICS ANNOUNCES UNITY BIOSYNC CONTACT LENSES WITH HYDRAMIST Unity BioSync Contact Lenses are premium daily disposable spherical contact lenses that provide ideal comfort and optical performance through a proprietary combination of silicone hydrogel material and proprietary polymer coating, exclusive to Unity BioSync. The lenses are made with HydraMist, which features unique moisture-retaining polymers for an increased level of hydration throughout the day.

HydraMist aims to improve the biocompatibility of the contact lens material and the surface of the eye to improve the overall experience for contact lens wearers. Unity BioSync has a base curve of 8.8 mm and a diameter of 14.1 mm. The power ranges include +8.00D to -10.00D. It offers a Dk/t value of 150, allowing more oxygen to reach the eyes, which is critical in preserving vision health. Unity BioSync will initially be available for patients through practices participating in the VSP Global Premier Program.

UnityContactLenses.com

COBURN TECHNOLOGIES ADDS OCULAR SURFACE ANALYZER The IDRA Ocular Surface Analyzer by SBM Sistemi is a fully automated, delegable, comprehensive dry eye diagnostic system that performs four non-invasive tests in just five minutes. Its integrated diagnostic platform is easy to use and helps determine which layers to treat in relation to the patient’s type of deficiency. IDRA’s non-invasive tests produce values that are displayed in a user-friendly grading scale that is ideal for patient engagement. Testing includes auto-interferometry, tear meniscus height measurement, auto-NIBUT, meibography and 3D meibomian gland imaging. Other possible examinations include bulbar redness classification, blepharitis and cylindrical dandruff testing, measurement of the pupil diameter and white-to-white measurement. The IDRA Ocular Surface Analyzer is the first in Coburn Technologies, Inc.’s diagnostic line of products.

CoburnTechnologies.com O p tometr ic O ffic e. c om | O c tob er /Novemb e r 2019

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AT-A- GLANCE

DAILY DISPOSABLE CONTACT LENSES MATERIAL/ Hî &#x;O

POWERS (D)

nelfilcon A/ 69%

+0.50D to +6.00D (0.25 steps) -0.50D to -6.00D (0.25D steps) +6.50D to +8.00D (0.50 steps) -6.50D to -15.00D (0.50D steps)

nesofilcon A/ 78%

Plano to -6.00D (0.25D steps) -6.50D to -9.00D (0.50D steps) +0.25D to +6.00D (0.25D steps)

hioxifilcon A/59%

-0.50D to -10.00D +0.50D to +6.00D (0.55D steps after -6.00D)

somofilcon A/ 56%

-10.00D to +8.00D (0.50D steps after +/-6.00D)

etafilcon A/ 58%

-0.50D to -6.00D (0.25D steps) -6.50D to -12.00D (0.50D steps) +0.50D to +6.00D (0.25D steps)

hioxifilcon A/ 57%

+0.50D to +4.00D (0.25D steps) -0.50D to -6.00D (0.25D steps) -6.50D to -10.00D (0.50D steps)

SynergEyes | 877.733.2012 | SynergEyes.com SimplifEyes 1 8.6/14.2 34 Day enhanced by Tangible

etafilcon A with Dual Tangible Polymers

+0.50D to +4.00D (0.25D steps) -0.50D to -6.00D (0.25D steps)

Unity Lenses | UnityContactLenses.com Unity BioSync 8.8/14.1 150 @-3.00D Contact Lenses with HydraMist

olifilcon B/ 47%

+0.50 to +6.00 (in 0.25D steps) +6.50 to +8.00 (in 0.50D steps) -0.50 to -6.00 (in 0.25D steps) -6.50 to -10.00 (in 0.50D steps)

BRAND

BC/DM (MM)

DK

Alcon Laboratories | 800.451.3937 | MyAlcon.com DAILIES 8.7/14.0 26 @ -3.00D AquaComfort Plus

Bausch + Lomb | 800.828.9030 | Bausch.com Biotrue ONEday

8.6/14.2

42 @ -3.00D

Clerio Vision | 650.440.6271 | ExtremeH20ContactLenses.com Extreme H2O 8.2, 8.5, and 8.7/13.6, 28 14.2 and 14.8

CooperVision | 800.341.2020 | CooperVision.com

clariti 1 day

8.6/14.1

60

Johnson & Johnson Vision | 800.843.2020 | JNJVisionPro.com

1-Day ACUVUE MOIST

8.5 or 9.0/14.2

25.5

Menicon America | 800.MENICON | MeniconAmerica.com Miru 1Day

8.6/14.2

25.38

Only one daily disposable contact lens from each company is listed here. For a longer listing go to OptometricOffice.com. O|O 16 Oct o be r / N o v e m b e r 2 0 1 9 | O p to m e tri c O f f i c e . c om

A child should never be limited by poor vision

Take the World Sight Day Challenge and help give the gift of sight Learn more, or sign up today at givingsight.org or call 303-526-0430

OPTOMETRYGIVINGSIGHT

Let’s Focus on Dry Eye! Please note: The availability of the products and features may differ in your country.

Specifications and design are subject to change. Please contact your local distributor for details.

Tear film assessment

Anterior segment imaging

Patient education and compliance

OCULUS Keratograph® 5M Dry Eye Evaluation and Topography The Keratograph® 5M incorporates analysis of the upper and lower meibomian glands along with other essential ocular surface testing.

Technician driven imaging brings efficiency to your pre- and post-op evaluations. All the information you need for your dry eye care!

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